Method and apparatus for coupling soft tissue to a bone

ABSTRACT

A method and apparatus for coupling a soft tissue implant into a locking cavity formed within a bone is disclosed. The apparatus includes a member to pull the soft tissue implant into a femoral tunnel. The member includes a suture having first and second ends which are passed through first and second openings associated with the longitudinal passage to form a pair of loops. A collapsible tube is positioned about the suture Application of tension onto the suture construction causes retraction of the soft tissue implant into the femoral tunnel and the collapse of the tube to form an anchor.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation U.S. patent application Ser. No.16/420,676, filed on May 23, 2019, which is a continuation U.S. patentapplication Ser. No. 15/793,216, filed on Oct. 25, 2017, which is acontinuation U.S. patent application Ser. No. 15/622,718, filed on Jun.14, 2017, which is a continuation U.S. patent application Ser. No.15/455,895, filed on Mar. 10, 2017, which is a continuation U.S. patentapplication Ser. No. 15/278,777, filed on Sep. 28, 2016, now U.S. Pat.No. 10,092,288 issued on Oct. 9, 2018, which is a continuation U.S.patent application Ser. No. 14/956,724, filed on Dec. 2, 2015, now U.S.Pat. No. 9,801,708 issued on Oct. 31, 2017, which is a continuation U.S.patent application Ser. No. 14/492,590, filed on Sep. 22, 2014, now U.S.Pat. No. 9,572,655 issued on Feb. 21, 2017, which is a divisional ofU.S. patent application Ser. No. 13/399,125 filed on Feb. 17, 2012, nowU.S. Pat. No. 8,840,645 issued on Sep. 23, 2014, which is a divisionalof U.S. patent application Ser. No. 12/196,410, filed on Aug. 22, 2008,now U.S. Pat. No. 8,118,836 issued on Feb. 21, 2012. The disclosures ofthe above applications are incorporated herein by reference.

FIELD

The present disclosure relates to method of coupling soft tissue to abone and, more particularly, to a method of implanting an ACL within afemoral tunnel.

BACKGROUND

The statements in this section merely provide background informationrelated to the present disclosure and may not constitute prior art.

It is commonplace in arthroscopic procedures to employ sutures andanchors to secure soft tissues to bone. Despite their widespread use,several improvements in the use of sutures and suture anchors ray bemade. For example, the procedure of tying knots may be very timeconsuming, thereby increasing the cost of the procedure and limiting thecapacity of the surgeon. Furthermore, the strength of the repair may belimited by the strength of the knot. This latter drawback may be ofparticular significance if the knot is tied improperly as the strengthof the knot in such situations may be significantly lower than thetensile strength of the suture material.

To improve on these uses, sutures having a single preformed loop havebeen provided. FIG. 1 represents a prior art suture construction. Asshown, one end of the suture is passed through a passage defined in thesuture itself. The application of tension to the ends of the suturepulls a portion of the suture through the passage, causing a loop formedin the suture to close. Relaxation of the system, however may allow aportion of the suture to translate back through the passage, thusrelieving the desired tension.

It is an object of the present teachings to provide an alternativedevice for anchoring sutures to bone and soft tissue. The device, whichis relatively simple in design and structure, is highly effective for isintended purpose.

SUMMARY

To overcome the aforementioned deficiencies, a method for configuring abraided tubular suture and a suture configuration are disclosed. Themethod includes passing a first end of the suture through a firstaperture into a passage defined by the suture and cut a second aperturedefined b the suture so as to place the first end outside of thepassage. A second end of the suture is passed through the secondaperture into the passage and out the first aperture so as to place thesecond end outside of the passage.

A method of surgically implanting a suture construction in a femoraltunnel is disclosed. A suture construction is formed by passing thesuture through a bore defined by a locking member. A first end of thesuture is passed through a first aperture within the suture into apassage defined by the suture and out a second aperture defined by thesuture so as to place the first end outside of the passage and define afirst loop. A second end of the suture is then passed through the secondaperture into the passage and out the first aperture so as to place thesecond end outside of the passage, and define a second loop. The firstand second ends and the first and second loops are then passed throughthe femoral tunnel. Soft tissue is then passed through the first andsecond loops. Tension is applied onto the first and second ends toconstrict the first and second loops to pull the soft tissue into thetunnel.

In another embodiment, a method of surgically implanting a suture isdisclosed. The suture is passed through a bore defined by a firstfastener. A suture construction is formed by passing the suture througha bore defined by a locking member. A first end of the suture is passedthrough a first aperture within the suture into a passage defined by thesuture and out a second aperture defined by the suture so as to placethe first end outside of the passage and define a first loop. A secondend of the suture is then passed through the second aperture into thepassage and out the first aperture so as to place the second end outsideof the passage, and define a second loop. A second fastener is coupledto at least one of the first and second loops. After the fastener iscoupled to the patient, tension is applied onto the first and secondends to constrict at least one of the first and second loops.

In another embodiment a method of surgically implanting a soft tissuereplacement for attaching two bone members is disclosed. A first andsecond tunnel is formed in first and second bones. A locking memberhaving a first profile which allows insertion of the locking memberthrough the tunnel and a second profile which allows engagement with thepositive locking surface upon rotation of the locking member isprovided. The suture construction described above is coupled to thelocking member. The first and second ends and the first and second loopsof the construction and the locking member are threaded through thefirst and second tunnels. Soft tissue is threaded through the first andsecond loops so as to engage bearing surfaces on the first and secondloops. The locking member is then engaged.

Further areas of applicability will become apparent from the descriptionprovided herein. It should be understood that the description andspecific examples are intended for purposes of illustration only and arenot intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustration purposes only and arenot intended to limit the scope of the present disclosure in any way.

FIG. 1 represents a prior art suture configuration;

FIGS. 2A and 2B represent suture constructions according to theteachings;

FIG. 3 represents the formation of the suture configuration shown inshown in FIG. 4A;

FIGS. 4A and 4B represent alternate suture configurations;

FIGS. 5-7 represent further alternate suture configurations;

FIG. 8 represents the suture construction according to FIG. 5 coupled toa bone engaging fastener;

FIGS. 9-11B represent the coupling of the suture construction accordingto FIG. 5 to a bone screw;

FIGS. 12A-12E represent the coupling of a soft tissue to an ACLreplacement in a femoral/humeral reconstruction;

FIGS. 13A-13D represent a close-up view of the suture shown in FIGS.1-11C;

FIGS. 14-16 represent fixed length textile anchors;

FIGS. 17-21 represent adjustable length textile anchors according to theteachings herein;

FIGS. 22-24 represent alternate adjustable length textile anchors;

FIGS. 25-27 represent alternate suture configurations;

FIG. 28 represents the preparation of the tibia and femur o accept theanchors disclosed in FIGS. 14-24;

FIGS. 29A and 29B represent the coupling of an ACL replacement in afemoral/tibial reconstruction using the textile anchor of FIG. 18;

FIGS. 30A and 30B represent the coupling of an ACL replacement in afemoral/tibial reconstruction using the textile anchor of FIG. 17;

FIGS. 31A and 31B represent the coupling of an ACL replacement in thefemoral/tibial reconstruction using the textile anchor of FIG. 15; and

FIGS. 32A and 32B represent the coupling of an ACL replacement in afemoral/humeral reconstruction using the textile anchor of FIG. 16.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is notintended to limit the present disclosure, application, or uses. Itshould be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.

FIG. 2A represents a suture construction 20 according to the presentteachings. Shown is a suture 22 having a first end 24 and a send end 26.The suture 22 is formed of a braided body 28 that defines alongitudinally formed hollow passage 30 therein. First and secondapertures 32 and 34 are defined in the braided body 28 at first andsecond locations of the longitudinally formed passage 30.

Briefly referring to FIG. 3, a first end 24 of the suture 22 is passedthrough the first aperture 32 and through longitudinal passage 30 formedby a passage portion and out the second aperture 34. The second end 26is passed through the second aperture 34, through the passage 30 and outthe first aperture 32. This forms two loops 46 and 46′. As seen in FIG.2B, the relationship of the first and second apertures 32 and 34 withrespect to the first and second ends 24 and 26 can be modified so as toallow a bow-tie suture construction 36. As described below, thelongitudinal and parallel placement of first and second suture portions38 and 40 of the suture 22 within the longitudinal passage 30 resiststhe reverse relative movement of the first and second portions 38 and 40of the suture once it is tightened.

The first and second apertures are formed during the braiding process asloose portions between pairs of fibers defining the suture. As furtherdescribed below, the first and second ends 24 and 26 can be passedthrough the longitudinal passage 30 multiple times. It is envisionedthat either a single or multiple apertures can be formed at the ends ofthe longitudinally formed passage.

As best seen in FIGS. 4A and 4B, a portion of the braided body 28 of thesuture defining the longitudinal passage 30 an be braided so as to havea diameter larger than the diameter of the first and second ends 24 and26. Additionally shown are first through fourth apertures 32, 34, 42,and 44. These apertures can be formed in the braiding process or can beformed during the construction process. In this regard, the apertures32, 34, 42, and 44 are defined between adjacent fibers in the braidedbody 28. As shown in FIG. 4B, and described below, it is envisioned thesutures can be passed through other biomedically compatible structures.

FIGS. 5-7 represent alternate constructions wherein a plurality of loops46 a-d are formed by passing the first and second ends 24 and 26 throughthe longitudinal passage 30 multiple times. The first and second ends 24and 26 can be passed through multiple or single apertures defined at theends of the longitudinal passage 30. The tensioning of the ends 24 and26 cause relative translation of the sides of the suture with respect toeach other.

Upon applying tension to the first and second ends 24 and 26 of thesuture 22, the size of the loops 46 a-d is reduced to a desired size orload. At this point, additional tension causes the body of the suturedefining the longitudinal passage 30 to constrict about the parallelportions of the suture within the longitudinal passage 30. Thisconstriction reduces the diameter of the longitudinal passage 30, thusforming a mechanical interface between the exterior surfaces of thefirst and second parallel portions as well as the interior surface ofthe longitudinal passage 30.

As seen in FIGS. 8-11, the suture construction can be coupled to variousbiocompatible hardware. In this regard, the suture construction 20 canbe coupled to an aperture 52 of the bone engaging fastener 54.Additionally, it is envisioned that soft tissue or bone engaging members56 can be fastened to one or two loops 46. After fixing the boneengaging fastener 54, the members 56 can be used to repair, forinstance, a meniscal tear. The first and second ends 24, 26 are thenpulled, setting the tension on the loops 46, thus pulling the meniscusinto place. Additionally, upon application of tension, the longitudinalpassage 30 is constricted, thus preventing the relaxation of the tensioncaused by relative movement of the first and second parallel portions38, 40, within the longitudinal passage 30.

As seen in FIGS. 9-11B, the loops 46 can be used to fasten the sutureconstruction 20 to multiple types of prosthetic devices. As describedfurther below, the suture 22 can Further be used to repair and couplesoft tissues in an anatomically desired position. Further, retraction ofthe first and second ends allows a physician to adjust the tension onthe loops between the prosthetic devices.

FIG. 11B represents the coupling of the suture construction according toFIG. 2B with a bone fastening member. Coupled to a pair of loops 46 and46′ is tissue fastening members 56. The application of tension to eitherthe first or second end 24 or 26 will tighten the loops 46 or 46′separately.

FIGS. 12A-12E represent potential uses of the suture constructions 20 inFIGS. 2A-7 in an ACL repair. As can be seen in FIG. 12A, thelongitudinal passage portion 30 of suture construction 20 can be firstcoupled to a fixation member 60. The member 60 can have a first profilewhich allows insertion of the member 60 through the tunnel and a secondprofile which allows engagement with a positive looking surface uponrotation. The longitudinal passage portion 30 of the suture construction20, member 60, loops 46 and ends 24, 26 can then be passed through afemoral and tibial tunnel 62. The fixation member 60 is positioned orcoupled to the femur. At this point, a natural or artificial ACL 64 canbe passed through a loop or loops 46 formed in the suture construction20. Tensioning of the first and second ends 24 and 26 applies tension tothe loops 46, thus pulling the ACL 64 into the tunnel. In this regard,the first and second ends are pulled through the femoral and tibialtunnel, thus constricting the loops 46 about the ACL 64 (see FIG. 12B).

As shown, the suture construction 20 allows for the application of forcealong an axis 61 defining the femoral tunnel. Specifically, theorientation of the suture construction 20 and, more specifically, theorientation of the longitudinal passage portion 30, the loops 46, andends 24, 26 allow for tension to be applied to the construction 20without applying non-seating forces to the fixation member 60. As anexample, should the loops 24, 26 be positioned at the member 60,application of forces to the ends 24, 26 may reduce the seating forceapplied by the member 60 onto the bone.

As best seen in FIG. 12C, the body portion 28 and parallel portions 38,40 of the suture construction 20 remain disposed within to the fixationmember 60. Further tension of the first ends draws the ACL 64 up throughthe tibial component into the femoral component. In this way, sutureends can be used to apply appropriate tension onto the ACL 64 component.The ACL 64 would be fixed to the tibial component using a plug or screwas is known. The suture construction has loops 46 and 46′ with a firstlength which allows rotation of the fixation member 60. Application oftension onto the ends 24, 26 of the sutures pulls the fixation member 60into position and the loops 46 and 46′ into a second length. In thisposition, rotation of the locking member in inhibited.

After feeding the ACL 64 through the loops 46, tensioning of the endsallows engagement of the ACL with bearing surfaces defined on the loops.The tensioning pulls the ACL 64 through a femoral and tibial tunnel. TheACL 64 could be further coupled to the femur using a transverse pin orplug. As shown in FIG. 12E, once the ACL is fastened to the tibia,further tensioning can be applied to the first and second ends 24, 26placing a desired predetermined load on the ACL. This tension can bemeasured using a force gauge. This load is maintained by the sutureconfiguration. It is equally envisioned that the fixation member 60 canbe placed on the tibial component 66 and the ACL pulled into the tunnelthrough the femur. Further, it is envisioned that bone cement orbiological materials may be inserted into the tunnel 62.

FIGS. 13A-13D represent a close-up of a portion of the suture 20. As canbe seen, the portion of the suture defining the longitudinal passage 30has a diameter d₁ which is larger than the diameter d₂ of the ends 24and 26. The first aperture 32 is formed between a pair of fiber members.As can be seen, the apertures 32, 34 can be formed between two adjacentfiber pairs 68, 70. Further, various shapes can be braided onto asurface of the longitudinal passage 30.

The sutures are typically braided of from 8 to 16 fibers. These fibersare made of nylon or other biocompatible material. It is envisioned thatthe suture 22 can be formed of multiple type of biocompatible fibershaving multiple coefficients of friction or size. Further, the braidingcan be accomplished so that different portions of the exterior surfaceof the suture can have different coefficients of friction or mechanicalproperties. The placement of a carrier fiber having a particular surfaceproperty can be modified along the length of the suture so as to placeit at varying locations within the braided constructions.

FIGS. 14-16 represent collapsible anchors 70, 72, 74 according to thepresent teachings. The anchors are deformable from a first cross sectionto a second engaging cross section. The anchors 70, 72, 74 arebiocompatible materials for example polymer or a knit or woven textilesuch as a braided nylon material. Disposed within a collapsible tube 76is a closed loop of suture material 78 which may form a portion of thecollapsible tube 76. Optionally, this collapsible tube 76 can beslidable with respect to the closed loop of suture material 78. Thecollapsible tube 76 is further collapsible to form a fabric mass 110(see for example FIG. 29B).

The suture material 78 can be passed through a pair of openings 83 inthe collapsible tube 76 a single time to form a single soft tissuebearing surface 80. Additionally, (see FIG. 15), the closed loop of thesuture material 78 can be looped over itself and passed through thecollapsible flexible tube 76 to form a pair of soft tissue bearingsurface portions 82. In each of the embodiments shown, the collapsibletube 76 defines at least one tube bearing surface.

FIG. 16 represents a closed loop of suture 78 passed through an aperture77 defined in a body 79 of the collapsible tube 76. In this regard, thesuture 78 is passed through a first open end 95 of the tube 78 andthrough the aperture 77 leaving a portion 81 of the collapsible tube 76which can be used to assist in the insertion of a graft to a patient(see FIG. 32A).

FIGS. 17-19 represent adjustable sized loops of suture material 78disposed within the collapsible tube 76 so as to form a suture anchorassembly 84, 86, 88. FIG. 17 shows the suture material 78 passed severaltimes through the collapsible tube 76. By applying tension to the ends90 and 92 of the suture material 78, the loops of the suture materialconstrict. If placed adjacent to a bearing surface (not shown), the end94 and 96 of the collapsible tube 76 are brought together, thuscollapsing the tube to form a collapsed material or fabric mass 110. Itis envisioned a portion of the suture material 78 can be passed throughthe collapsible tube (75) to help maintain the position of the suturewith respect to the collapsible tube 76.

FIGS. 18 and 19 show the loops of the suture construction of FIG. 4awithin a collapsible tube 76. The tubular portion of the construction ofFIG. 4a can be disposed either within or outside of the collapsible tube76. As with the embodiment shown in FIGS. 14-16, translation of the tube78 with respect to the suture material 78 can cause the ends 94 of thetube 76 to be brought together to compress the loops 76 into a fabricmass 110.

FIGS. 20 and 21 show the loops of FIGS. 2B, 4A or 5 disposed within thecollapsible tube 76. Shown are the ends and loops disposed at leastpartially through a portion 100 of the tube 76. Tensioning of the ends24, 26 causes the portions 100 of the tube 76 to collapse to form a mass110, while leaving other portions 85 uncollapsed. The outer uncollapsedportion 85 can function as a bearing surface to assist in the collapseof portion 100 when portion 100 is subjected to compressive loads.

FIG. 21 shows an embodiment where suture loops are passed through thesidewalls of the collapsible tube 76. Optionally, the loops 46 and 47 aswell as the ends 24 and 26 can be passed through together. Thisconstruction can be used in situations where a large collapsed mass 110is needed

FIG. 22 shows the loop of FIG. 2B having a pair of collapsible tubes 76.The collapsible tubes 76 are disposed about the loops 46 and 46′ andwill collapse upon application of tension to the ends of the sutureconstruction in a manner which places compressive loads onto the ends ofthe tube 76. It is envisioned that these collapsible tubes 76 can becollapsed simultaneously or staggered in time as needed by a treatingphysician. It is also envisioned that the loop construction can be usedto pull adjacent portions of a patient's anatomy together.

FIG. 23 depicts the loop construction shown in FIG. 2A having its loopsdisposed through a pair of co-joined crossed collapsible tubes 76. Ifplaced adjacent to a bearing surface, the ends of the co-joined tubescome together, thus increasing in cross-section. This forms the fabricmass 110. This construction can be used in situations where a largecollapsed mass is needed.

FIG. 24 shows the complex suture construction which embodies a pair ofsuture constructions of FIG. 2A coupled together using a passages 30 and30′ formed in the suture material 22. Portions of the suture 22 arelooped through each other to form a pair of locked loops 112. Thisconstruction can be used to provide a static seat for a graft bearingsurface.

FIGS. 25-27 represent alternate suture constructions where the ends ofthe sutures 22 are fed multiple times through holes 105 defined withinlongitudinal passage 30 of the suture to form adjustable loops 46. Insituations where relaxation of a tightened construction is to beminimized, the ends can be passed in and out of the passage 30 severaltimes. In this regard, the first and second ends are positioned so as tobe parallel and adjacent to each other in the passage 30.

FIGS. 26 and 27 represent constructions where the first and second ends24 and 26 a passed through the same passage 30, but do not overlap andare not adjacent. This construction may be useful for joining pairs ofmembers. This construction would be useful to bind pairs of appendagessuch as fingers.

FIG. 28 represents the formation of a femoral tunnel shown as a tunnel62 having a varying diameter. Disposed within either the femoral ortibial tunnel 62 are a first portion 102 having a first diameter and asecond portion 104 having a second diameter larger than the firstdiameter. Defined on an exterior surface of either the tibia or femur isa bearing surface 103, which is configured to interface with the fabricmass 110 of compressed textile material to prevent the relative motionof the fabric mass 110, and thus the suture construction with respect tothe bone. This bearing surface can be machined or natural.

FIGS. 29A and 29B represent potential uses of the suture construction 86in FIG. 18 in an ACL repair. As can be seen in FIG. 29A, thelongitudinal passage portion 30 of suture construction 86 an be firstcoupled to a collapsible tube 76. The tube 76 can have a first profilewhich allows insertion of the tube 76 through the tunnel 62 and a secondcross-sectional profile which allows engagement with a positive lockingsurface 103 upon collapse of the collapsible tube 76 into the fabricmass 110. The longitudinal passage portion 30 of the suture construction84, tube 76, loops 46 and ends 24, 26 can then be pulled through afemoral and tibial tunnel 62. The tube 76 is positioned or coupled tothe femur. At this point, a natural or artificial ACL 64 can be passedthrough a loop or loops 46 formed in the suture construction 20 or canbe supported by the passage portion 30. Tensioning of the first andsecond ends 24 and 26 applies tension to the loops 46 and 47, thuspulling the ACL 64 into the tunnel. In this regard, the first and secondends are pulled through the femoral and tibial tunnel 62, thusconstricting the loops 46 about the ACL 64.

After feeding the ACL 64 through the loops 46, tensioning of the endsallows engagement of the ACL, with bearing surfaces defined on theloops. The tensioning pulls the ACL 64 through a femoral and tibialtunnel and collapses the tube 76 to form a locking fabric mass 110outside the bone or tunnel 62. The ACL 64 could be further coupled tothe femur or tibia using a transverse pin or plug. As shown in FIG. 29B,once the ACL is fastened to the tibia, further tensioning can be appliedto the first and second ends 24, 26 placing a desired predetermined loadon the ACL. As described above, this tension can be measured using aforce gauge. This load is maintained by the suture configuration. It isequally envisioned that the fixation member 60 can be placed on thetibial component 66 and the ACL pulled into the tunnel through thefemur. Further, it is envisioned that bone cement or biologicalmaterials may be inserted into the tunnel 62. The longitudinal passage30 resists relaxation or reverse movement of the suture.

As best seen in FIG. 29B, the body portion 28 and parallel portions 38,40 of the suture construction 86 remain disposed within the femoraltunnel 62. Further tension of the first ends draws the ACL 64 up throughthe tibial component into the femoral component. In this way, sutureends can be used to apply appropriate tension onto the ACL 64 component.The ACL 64 would be fixed to the tibial component using a plug or screweither before or after the application of the tension to the suture 22.Additionally, tension can be set on the ACL 64 after the collapsibletube 76 has been compressed.

FIGS. 30A and 30B represent potential uses of the suture constructions84 in FIG. 17 in an ACL repair. As can be seen in FIG. 30A, thelongitudinal passage portion 30 of suture construction 86 can be firstdisposed within the tube 76. The tube 76 has a first profile whichallows insertion of the tube 76 through the tunnel and a secondcollapsed profile which allows engagement with a positive lockingsurface 103. The collapsible tube 76 of the suture construction 84,member 60, and loops 46, 47 can then be passed through a femoral andtibial tunnel 62 using a suture 108. The tube 76 is positioned orcoupled to the femur. At this point, a natural or artificial ACL 64 canbe passed through a loop or loops 46, 47 formed in the sutureconstruction 84. Tensioning of the first and second ends 24 and 26applies tension to the loops 46, 47 thus pulling the ACL 64 into thetunnel. In this regard, the first and second ends 26 and 24 are pulledthrough the femoral and tibial tunnel, thus constricting the loops 46about the ACL 64 (see FIG. 30B) and collapsing the tube 76 to form theanchoring mass 110. Forces applied to graft 64 along axis 61 in thedistal direction will seat tube 76 and form anchoring mass 110.

As shown, by holding the suture construction in place 108, the sutureconstruction 84 allows for the application of force along an axis 61defining the femoral tunnel 62. Specifically, the orientation of thesuture construction 84 and, more specifically, the orientation of thelongiludinal passage portion 30, the loops 46, and ends 24, 26 allow fartension to be applied to the construction 86 without applyingnon-seating forces to the tube 76. As an example, should the loops 24,26 be positioned at the tube 76, application of forces to the ends 24,26 may reduce the seating force applied by the tube 78 onto the bone.

As best seen in FIG. 30B, the loop portions 46, 47 of the sutureconstruction 84 remain disposed within to the tunnel 62. Further tensionof the first ends draws the ACL 64 up through the tibial component intothe femoral component. In this way, suture ends can be used to applyappropriate tension onto the ACL 64 component. The ACL 64 would be fixedto the tibial component using a plug or screw 60 adjacent the sutureconstruction 84, as is known.

Alternatively, as shown in FIG. 30B, once the ACL is fastened to thetibia, further tensioning can be applied to the first and second ends24, 26 placing a desired predetermined load on the ACL. This load ismaintained by the suture configuration. It is equally envisioned thatthe fixation member 60 can be placed on the tibial component 66 and theACL pulled into the tunnel through the femur. Further, it is envisionedthat bone cement or biological materials may be inserted into the tunnel62.

FIGS. 31A and 31B represent potential uses of the suture construction 70in FIG. 14 in an ACL repair. The suture material 78 of sutureconstruction 70 can be first coupled to a collapsible tube 76. Thecollapsible tube 76 can have a first profile which allows insertion ofthe construction 70 through the tunnel and a second profile which allowsengagement with a positive locking surface 103 upon its compression.Prior to attachment to the femur, a natural or artificial ACL 64 can bepassed through a loop or loops 46 formed in the suture material 78.Suture construction 70 can then be passed through a femoral and tibialtunnel 62. The tube 76 is positioned or coupled to the femur. Tensioningof the first and second ends 112 and 114 of the soft tissue appliestension to the loop 76, thus collapsing the tube 76 to form the fabricmass 110. Tension can be applied to the soft tissue which can then befastened to the tibia using a fastener 60.

FIGS. 32A and 32B represent potential uses of the suture constructions74 in FIG. 16 in an ACL repair. The loop of suture 78 is coupled to acollapsible tube 76. The construction 74 can have a first profile whichallows insertion of the tube 76 through the tunnel and a second profilewhich allows engagement with a positive locking surface uponcompression. The suture portion 78 of the suture construction 74, tube76, and soft tissue 64 can then be passed through a femoral and tibialtunnel 62. The tube 76 is positioned or coupled to the femur 103 andcollapsed by the application of tension to the soft tissue 64.

As best seen in FIG. 32B, the anchoring mass 110 of the sutureconstruction 72 remains disposed outside the femoral tunnel. Tension isapplied to the ends of the ACL 64 up through the tibial component intothe femoral component. In this way, ends of the ACL 112, 114 can be usedto apply appropriate tension onto the ACL 64 component. The ACL 64 wouldbe fixed to the tibial component using a plug or screw as is known.

The description of the invention is merely exemplary in nature and,thus, variations that do not depart from the gist of the invention areintended to be within the scope of the invention. For example, any ofthe above mentioned surgical procedures is applicable to repair of otherbody portions. For example, the procedures can be equally applied to therepair of wrists, elbows, ankles, and meniscal repair. The suture loopscan be passed through bores formed in soft or hard tissue, it is equallyenvisioned that the loops can be passed through or formed around anaperture or apertures formed in prosthetic devices e.g. humeral, femoralor tibial stems. Such variations are not to be regarded as a departurefrom the spirit and scope of the invention.

1.-18. (canceled)
 19. A bone fixation assembly, comprising: anadjustable suture construct that includes a suture with a first free endand a second free end, the suture further comprising a first aperture, afourth aperture, a third aperture, and a second aperture which are allseparate apertures in the suture and which occur successively along thesuture such that, in a direction from the first free end to the secondfree end, the first aperture precedes the fourth aperture, the fourthaperture precedes the third aperture, and the third aperture precedesthe second aperture, wherein the first free end extends into the suturethrough the first aperture, longitudinally within the suture between thefirst aperture and the fourth aperture, and out of the suture throughthe fourth aperture to form a first adjustable loop, and wherein thesecond free end extends into the suture through the second aperture,longitudinally within the suture between the second aperture and thethird aperture, and out of the suture through the third aperture to forma second adjustable loop, wherein, with the first adjustable loop andthe second adjustable loop formed, the first free end can be pulled todecrease a size of the first adjustable loop and the second free end canbe pulled to decrease a size of the second adjustable loop; and a bonefixation member coupled to the adjustable suture construct.
 20. The bonefixation assembly of claim 19, wherein the first free end of the sutureextends through the first aperture and the fourth aperture withoutextending through the second aperture or the third aperture, and whereinthe second free end of the suture extends through the second apertureand the third aperture without extending through the first aperture orthe fourth aperture.
 21. The bone fixation assembly of claim 19, whereinthe first free end and the second free end both extend longitudinallywithin the suture adjacent the bone fixation member.
 22. The bonefixation assembly of claim 19, wherein the third aperture and the fourthaperture are both positioned adjacent the bone fixation member.
 23. Thebone fixation assembly of claim 19, wherein the first free end can bepulled to decrease a size of the first adjustable loop withoutdecreasing a size of the second adjustable loop, and wherein the secondfree end can be pulled to decrease a size of the second adjustable loopwithout decreasing a size of the first adjustable loop.
 24. The bonefixation assembly of claim 19, wherein the first adjustable loop and thesecond adjustable loop are looped through one another.
 25. The bonefixation assembly of claim 19 further comprising an ACL graft coupled tothe adjustable suture construct.
 26. A method of constructing anadjustable suture construct, comprising: passing a first free end of asuture: (i) into the suture through a first aperture in the suture; (ii)longitudinally within the suture between the first aperture and a fourthaperture in the suture; and (iii) out of the suture through the fourthaperture to form a first adjustable loop; and passing a second free endof the suture: (i) into the suture through a second aperture in thesuture; (ii) longitudinally within the suture between the secondaperture and a third aperture in the suture; and (iii) out of the suturethrough the third aperture to form a second adjustable loop, wherein thefirst aperture, the fourth aperture, the third aperture, and the secondaperture are all separate apertures in the suture and occur successivelyalong the suture such that, in a direction from the first free end tothe second free end, the first aperture precedes the fourth aperture,the fourth aperture precedes the third aperture, and the third apertureprecedes the second aperture, and wherein, with the first adjustableloop and the second adjustable loop formed, the first free end can bepulled to decrease a size of the first adjustable loop and the secondfree end can be pulled to decrease a size of the second adjustable loop.27. The method of claim 26 further comprising coupling a first bonefixation member to the suture.
 28. The method of claim 27, wherein saidcoupling leaves the third aperture and the fourth aperture within thefirst bone fixation member.
 29. The method of claim 27, wherein saidcoupling leaves the third aperture and the fourth aperture adjacent thefirst bone fixation member.
 30. The method of claim 27 furthercomprising coupling a second bone fixation member to the suture.
 31. Themethod of claim 26, wherein, with the first adjustable loop and thesecond adjustable loop formed, the first free end can be pulled todecrease a size of the first adjustable loop without decreasing a sizeof the second adjustable loop and the second free end can be pulled todecrease a size of the second adjustable loop without decreasing a sizeof the first adjustable loop.
 32. The method of claim 26, wherein thefirst free end of the suture extends through the first aperture and thefourth aperture without extending through the second aperture or thethird aperture, and wherein the second free end of the suture extendsthrough the second aperture and the third aperture without extendingthrough the first aperture or the fourth aperture.
 33. The method ofclaim 26 further comprising looping the first adjustable loop throughthe second adjustable loop.
 34. The method of claim 26 furthercomprising coupling a deformable tube to the suture.
 35. The method ofclaim 34, wherein the deformable tube provides a longitudinal passageextending through the deformable tube from a first open end of thedeformable tube to a second open end of the deformable tube, and whereinat least the first adjustable loop of the adjustable suture constructextends through at least part of the longitudinal passage in thedeformable tube so that the deformable tube is received on theadjustable suture construct.
 36. The method of claim 34, wherein thefirst free end and the second free end both extend longitudinally withinthe suture within at least part of the longitudinal passage in thedeformable tube.
 37. The method of claim 26 further comprising couplinga soft tissue graft to the suture.
 38. The method of claim 37, whereinthe soft tissue graft is an ACL graft.